Chapter19

19. Patient Teaching

Keep Your Feet and Skin Healthy

What are diabetes problems?

What should I do each day to stay healthy with diabetes?

How can diabetes hurt my feet?

What can I do to take care of my feet?

How can I get my doctor to help me take care of my feet?

What are common diabetes foot problems?

How can special shoes help my feet?

How can diabetes hurt my skin?

What can I do to take care of my skin?

For more information

What Are Diabetes Problem?

Too much sugar in the blood for a long time causes diabetes problems. This high-blood sugar can damage many parts of the body, such as the heart, blood vessels, and kidneys. Diabetes problems can be scary, but there is a lot you can do to prevent them or slow them down.

This chapter is about feet and skin problems caused by diabetes. You will learn the things you can do each day and during each year to stay healthy and prevent diabetes problems.

What Should I Do Each Day to Stay Healthy With Diabetes

	Follow the healthy eating plan that you and your doctor or dietitian have worked out. Eat your meals and snacks at around the same times each day.
	Be active a total of 30 minutes most days. Ask your doctor what activities are best for you.
	Take your diabetes medicine at the same times each day.
	Check your blood sugar every day. Each time you check your blood sugar, write the number in your record book. Call your doctor if your numbers are too high or too low for 2 to 3 days.
	Check your feet every day for cuts, blisters, sores, swelling, redness, or sore toenails.
	Brush and floss your teeth and gums every day.
	Don’t smoke.

How Can Diabetes Hurt My Feet?

High blood sugar from diabetes causes two problems that can hurt your feet:

	Nerve damage. One problem is damage to nerves in your legs and feet. With damaged nerves, you might not feel pain, heat, or cold in your legs and feet. You might let a sore or cut on your foot get worse because you do not know it is there. This lack of feeling is called diabetic neuropathy (ne-ROP-uh-thee). It can lead to a large sore or infection.
	Poor blood flow. The second problem happens when not enough healthy blood flows to your legs and feet. Poor blood flow makes it hard for a sore or infection to heal. This problem is called peripheral (puh-RIF-uh-rul) vascular disease. Smoking when you have diabetes makes blood flow problems much worse.

These two problems can work together to cause a foot problem.

For example, you get a blister from shoes that do not fit. You do not feel the pain from the blister because you have nerve damage in your foot. Next, the blister gets infected. If blood sugar is high, the extra sugar feeds the germs. Germs grow and the infection gets worse. Poor blood flow to your legs and feet can slow down healing. Once in a while a bad infection never heals. The infection might cause gangrene (GANG-green). If a person has gangrene, the skin and tissue around the sore die. The area becomes black and smelly.

To keep gangrene from spreading, a doctor may have to do surgery to cut off a toe, foot, or part of a leg. Cutting off a body part is called an amputation (amp-yoo-TAY-shun).

What Can I Do to Take Care of My Feet?

Wash your feet in warm water every day. Make sure the water is not too hot by testing the temperature with your elbow. Do not soak your feet. Dry your feet well, especially between your toes.

Look at your feet every day to check for sores, blisters, redness, calluses, or other problems. Checking every day is even more important if you have nerve damage or poor blood flow. If you cannot bend over or pull your foot up to check your feet, use a mirror. If you cannot see well, ask someone else to check your feet.

If your skin is dry, rub lotion on your feet after you wash and dry them. Do not put lotion between your toes.

File corns and calluses gently with an emery board or pumice stone. Do this after your bath or shower. Move the emery board in only one direction.

Cut your toenails once a week. Cut toenails when they are soft from washing.Cut them to the shape of the toe and not too short. Do not cut into the corners because you might cut the skin. Sharp edges can make a sore that can get infected. File toenails with an emery board. If you cannot cut your own toenails, ask someone who can or go to a foot doctor.

Always wear shoes or slippers. Never walk barefoot, even when you are at home.

Always wear socks or stockings. Do not wear socks or knee-high stockings that are too tight below your knee.

Wear shoes that fit well. Buy shoes made of canvas or leather. Shop for shoes at the end of the day when your feet are bigger. Break in shoes slowly. Wear them 1 to 2 hours each day for the first 1 to 2 weeks.

Only use medicines your doctor tells you to use.

How Can I Get My Doctor To Take Care of My Feet?

Tell your doctor right away about any foot problems.

Ask your doctor to look at your feet at each diabetes checkup. To make sure your doctor checks your feet, take off your shoes and socks before your doctor comes into the room.

Ask your doctor to check how well the nerves in your feet sense feeling.

Ask your doctor to check how well blood is flowing to your legs and feet.

Ask your doctor to show you the best way to trim your toenails. Ask what lotion or cream to use on your legs and feet.

If you cannot cut your toenails or you have a foot problem, ask your doctor to send you to a foot doctor. A doctor who cares for feet is called a podiatrist (puh-DY-uh-trist).

What Are Common Diabetes Foot Problem?

Anyone can have corns, blisters, and athlete’s foot. If you have diabetes and your blood sugar stays high, these foot problems can lead to infections.

Corns and calluses are thick layers of skin caused by too much rubbing or pressure on the same spot. Corns and calluses can become infected.

Blisters can form if shoes always rub the same spot. Wearing shoes that do not fit or wearing shoes without socks can cause blisters. Blisters can become infected.

Ingrown toenails happen when an edge of the nail grows into the skin. The skin can get red and infected. Ingrown toenails can happen if you cut into the corners of your toenails when you trim them. If toenail edges are sharp, smooth them with an emery board. You can also get an ingrown toenail if your shoes are too tight.

A bunion forms when your big toe slants toward the small toes and the place between the bones near the base of your big toe grows big. This spot can get red, sore, and infected. Bunions can form on one or both feet. Pointy shoes may cause bunions. Bunions often run in the family. Surgery can remove bunions.

Plantar warts are caused by a virus. The warts usually form on the bottoms of the feet and tend to go away without treatment.

Hammertoes form when a foot muscle gets weak. The weakness may be from diabetic nerve damage. The weakened muscle makes the tendons in the foot shorter and makes the toes curl under the feet. You may get sores on the bottoms of your feet and on the tops of your toes. The feet can change their shape. Hammertoes can cause problems with walking and finding shoes that fit well. Hammertoes can run in the family. Wearing shoes that are too short can also cause hammertoes.

Dry and cracked skin can happen because the nerves in your legs and feet do not get the message to keep your skin soft and moist. Dry skin can become cracked and allow germs to enter. If your blood sugar is high, sugar feeds the germs and makes the infection worse.

Athlete’s foot is a fungus that causes redness and cracking of the skin. It is itchy. The cracks between the toes allow germs to get under the skin. If blood sugar is high, the sugar feeds the germs and makes the infection worse. The infection can spread to the toenails and make them thick, yellow, and hard to cut.

All of these foot problems can be taken care of. Tell your doctor about any foot problem as soon as you see it.

How Can Special Shoes Help My Feet?

Special shoes can be made to fit softly around your sore feet or feet that have changed shape. These special shoes help protect your feet. Medicare and other health insurance programs may pay for special shoes. Talk to your doctor about how and where to get them.

How Can Diabetes Hurt My Skin?

Diabetes can hurt your skin in two ways:

If your blood sugar is high, your body loses fluid. With less fluid in your body, your skin can get dry. Dry skin can be itchy, causing you to scratch and make it sore. Also, dry skin can crack. Cracks allow germs to enter and cause infection. If your blood sugar is high, the sugar feeds germs and makes infections worse. Skin can get dry on your legs, feet, elbows, and other places on your body.

Skin can also get dry because the nerves in your legs and feet do not get the message to sweat. Sweating helps keep your skin soft and moist.

What Can I Do to take Care of My Skin?

After you wash with a mild soap, make sure you rinse and dry yourself well. Check places where water can hide, such as under the arms, under the breasts, between the legs, and between the toes.

Keep your skin moist by washing with a mild soap and using lotion or cream after you wash.

Keep your skin moist by using a lotion or cream after you wash. Ask your doctor to suggest one.

Drink lots of fluids, such as water, to keep your skin moist and healthy.

Wear all-cotton underwear. Cotton allows air to move around your body better.

Look at your body after you wash. Make sure you have no dry, red, or sore spots that might lead to an infection.

Tell your doctor about any skin problems.

Source: National Institutes of Arthritis and Musculoskeletal and Skin Diseases

National Institutes of Health

Take Care of Your Feet for a Lifetime

You can take care of your feet!

Do you want to avoid serious foot problems that can lead to a toe, foot, or leg amputation? Take Care of Your Feet for a Lifetime tells you how. It’s all about taking good care of your feet.

Foot care is very important for each person with diabetes, but especially if you have:

Loss of feeling in your feet.

Changes in the shape of your feet.

Foot ulcers or sores that do not heal.

Nerve damage can cause you to lose feeling in your feet. You may not feel a pebble inside your sock that is causing a sore. You may not feel a blister caused by poorly fitting shoes. Foot injuries such as these can cause ulcers which may lead to amputation.

Keeping your blood glucose (sugar) in good control and taking care of your feet every day can help you avoid serious foot problems.

Use this guide to make your own plan for taking care of your feet. Helpful tips make it easy! Share your plan with your doctor and health-care team and get their help when you need it.

There is a lot you can do to prevent serious problems with your feet. Here’s how.

1. Take care of your diabetes.

• Make healthy lifestyle choices to help keep your blood glucose (sugar), blood pressure, and cholesterol close to normal. Doing so may help prevent or delay diabetes-related foot problems as well as eye and kidney disease.

• Work with your health-care team to make a diabetes plan that fits your lifestyle. The team may include your doctor, a diabetes educator, a nurse, a dietitian, a foot care doctor called a podiatrist (pah-DI-ah-trist), and other specialists. This team will help you to:

Know when to get checks of your A1C,* blood pressure, and cholesterol.

Know how and when to test your blood glucose.

Take your medicines as prescribed.

Eat regular meals that contain a variety of healthy, low-fat, high-fiber foods including fruits and vegetables each day.

Get physical activity each day.

Stop smoking.

Follow your foot care plan.

Keep your doctor’s visits and have your feet, eyes, and kidneys checked at least once a year. Visit your dentist twice a year.

2. Check your feet every day.

You may have serious foot problems, but feel no pain. Check your feet for cuts, sores, red spots, swelling, and infected toenails. Find a time (evening is best) to check your feet each day. Make checking your feet part of your every day routine.

If you have trouble bending over to see your feet, use a plastic mirror to help. You also can ask a family member or caregiver to help you.

3. Wash your feet every day.

Wash your feet in warm, not hot, water. Do not soak your feet, because your skin will get dry.

Before bathing or showering, test the water to make sure it is not too hot. You can use a thermometer (90° to 95° F is safe) or your elbow.

Dry your feet well. Be sure to dry between your toes. Use talcum powder or cornstarch to keep the skin between your toes dry.

4. Keep the skin soft and smooth.

Rub a thin coat of skin lotion, cream, or petroleum jelly on the tops and bottoms of your feet.

Do not put lotion or cream between your toes, because this might cause an infection.

5. Smooth corns and calluses gently.

If you have corns and calluses, check with your doctor or foot care specialist about the best way to care for them.

If your doctor tells you to, use a pumice stone to smooth corns and calluses after bathing or showering. A pumice stone is a type of rock used to smooth the skin. Rub gently, only in one direction, to avoid tearing the skin.

Do not cut corns and calluses. Don’t use razor blades, corn plasters, or liquid corn and callus removers– they can damage your skin.

6. Trim your toenails each week or when needed..

Trim your toenails with clippers after you wash and dry your feet.

Trim toenails straight across and smooth them with an emery board or nail file.

Don’t cut into the corners of the toenail.

If you can’t see well, if your toenails are thick or yellowed, or if your nails curve and grow into the skin, have a foot care doctor trim them.

7. Wear shoes and socks at all times.

Wear shoes and socks at all times. Do not walk barefoot – not even indoors –because it is easy to step on something and hurt your feet.

Always wear socks, stockings, or nylons with your shoes to help avoid blisters and sores.

Choose clean, lightly padded socks that fit well. Socks that have no seams are best.

Check the insides of your shoes before you put them on to be sure the lining is smooth and that there are no objects in them.

Wear shoes that fit well and protect your feet.

8. Protect your feet from hot and cold.

Wear shoes at the beach or on hot pavement.

Put sunscreen on the top of your feet to prevent sunburn.

Keep your feet away from radiators and open fires.

Do not put hot water bottles or heating pads on your feet.

Protect your feet from hot and cold.

Wear socks at night if your feet get cold. Lined boots are good in winter to keep your feet warm.

Check your feet often in cold weather to avoid frostbite.

Make sure to call your doctor right away if a cut, sore, blister, or bruise on your foot does not begin to heal after one day.

9. Keep the blood flowing to your feet.

Put your feet up when you are sitting.

Wiggle your toes for 5 minutes, 2 or 3 times a day. Move your ankles up and down and in and out to improve blood flow in your feet and legs.

Don’t cross your legs for long periods of time.

Don’t wear tight socks, elastic or rubber bands, or garters around your legs.

Don’t smoke. Smoking reduces blood flow to your feet. Ask for help to stop smoking.

Work with your health-care team to control your A1C (blood glucose), blood pressure and cholesterol.

10. Be more active.

Ask your doctor to help you plan a daily activity program that is right for you.

Walking, dancing, swimming, and bicycling are good forms of exercise that are easy on the feet.

Avoid activities that are hard on the feet, such as running and jumping.

Always include a short warm-up and cool-down period.

Wear athletic shoes that fit well and that provide good support.

Make sure to call your doctor right away if a cut, sore, blister, or bruise on your foot does not begin to heal after one day.

11. Be sure to ask your doctor to

Check the sense of feeling and pulses in your feet at least once a year.

Tell you if you are likely to have serious foot problems. If you have serious foot problems, your feet should be checked at every visit to your doctor.

Show you how to care for your feet.

Refer you to a foot care doctor if needed.

Decide if special shoes would help your feet stay healthy.

12. Get started now.

Begin taking good care of your feet today.

Set a time every day to check your feet.

Note the date of your next visit to the doctor.

Print out the foot care tip sheet* and put it on your bathroom or bedroom wall or nightstand as a reminder.

Print out and complete the "To Do" list*. Get started now.

Set a date for buying the things you need to take care of your feet: nail clippers, pumice stone, emery board, skin lotion, talcum powder, plastic mirror, socks, athletic shoes, and slippers.

Most important, stick with your foot care program .... and give yourself a special treat such as a new pair of lightly padded socks with no seams. You deserve it!

Make sure to call your doctor right away if a cut, sore, blister, or bruise on your foot does not begin to heal after one day.

Tip For Proper Footwear

Proper footwear is very important for preventing serious foot problems. Athletic or walking shoes are good for daily wear. They support your feet and allow them to "breathe."

Never wear vinyl or plastic shoes, because they don’t stretch or "breathe."

When buying shoes, make sure they are comfortable from the start and have enough room for your toes.

Don’t buy shoes with pointed toes or high heels. They put too much pressure on your toes.

Ask your doctor about Medicare or other insurance coverage for special footwear.

You may need special shoes or shoe inserts to prevent serious foot problems. If you have Medicare Part B insurance, you may be able to get some of the cost of special shoes or inserts paid for. Ask your doctor whether you qualify for

1 pair of depth shoes* and 3 pairs of inserts, or

1 pair of custom molded shoes (including inserts) and 2 additional pairs of inserts.

If you qualify for Medicare or other insurance coverage, your doctor or podiatrist will tell you how to get your special shoes.

* Depth shoes look like athletic or walking shoes, but have more room in them. The extra room allows for different shaped feet and toes, or for special inserts made to fit your feet.

Steps For Preventing Diabetes Foot Problems

1. Perform a comprehensive foot exam annually.

Examine skin, hair, toenails, musculoskeletal structure, and evaluate vascular status, and protective sensation.

Inspect footwear for proper fit, appropriate materials, foreign objects, torn linings, and proper cushioning.

Low Risk

All of the following:

High Risk

One or more of the following:

Intact protective sensation

Pedal pulses present

No foot deformity

No current or prior foot ulcer

No amputation

Loss of protective sensation

Absent pedal pulses

Foot deformity.

History of foot ulcer

Prior amputation

3. Document your findings in the medical record.

4. Counsel your patients and/or refer to a diabetes educator.

Talk with your patients about their risk category.

Demonstrate self-care techniques.

Prescribe appropriate footwear.

Give positive feedback for proper foot care.

Give patients the self-care tip sheet in this kit.

Counsel about smoking cessation if needed.

Reinforce the importance of blood glucose control to reduce the risk for foot problems and other complications.

5. Follow up with low risk patients.

Visually inspect feet at subsequent visits as warranted.

Inspect footwear at every visit as warranted.

6. Follow up with high risk patients.

Place a "high risk feet" sticker on medical record.

Visually inspect feet at every visit.

Inspect footwear at every visit.

Prescribe special inserts and shoes as needed.

Refer to specialists for a risk factor you cannot rectify.

Ensure that the elderly and blind have help for daily foot care.

Annual Comprehensive Diabetes Food Exam

A physician or other trained health care provider should complete this exam and document findings in the medical record.Conducting an annual comprehensive diabetes foot exam will enable you to:

Note the presence of any diabetes complications (eye, kidney, nerve, vascular).

Note history or presence of foot ulcer.

Examine the ankles and feet, including between the toes. Visually inspect hair, skin, and nails and note abnormalities on the foot diagram.

Use this ruler to measure calluses, lesions, and ulcers.

Note deformities and atrophy of plantar fat pad.

Check pedal pulses.

Perform a sensory exam at five sites with a 5.07 (10-gram)

Semmes - Weinstein monofilament and note results .

Determine the patient’s risk status.

Check the patient’s footwear.

Determine the patient’s education needs.

Complete a management plan for education, diagnostic studies, footwear recommendations, referrals, and follow-up visits.

	If your skin is dry, rub lotion on your feet after you wash and dry them. Do not put lotion between your toes.
	File corns and calluses gently with an emery board or pumice stone. Do this after your bath or shower. Move the emery board in only one direction.
	Cut your toenails once a week. Cut toenails when they are soft from washing.Cut them to the shape of the toe and not too short. Do not cut into the corners because you might cut the skin. Sharp edges can make a sore that can get infected. File toenails with an emery board. If you cannot cut your own toenails, ask someone who can or go to a foot doctor.

	Ask your doctor to check how well blood is flowing to your legs and feet.
	Ask your doctor to show you the best way to trim your toenails. Ask what lotion or cream to use on your legs and feet.
	If you cannot cut your toenails or you have a foot problem, ask your doctor to send you to a foot doctor. A doctor who cares for feet is called a podiatrist (puh-DY-uh-trist).

	After you wash with a mild soap, make sure you rinse and dry yourself well. Check places where water can hide, such as under the arms, under the breasts, between the legs, and between the toes.
	Keep your skin moist by washing with a mild soap and using lotion or cream after you wash.
	Keep your skin moist by using a lotion or cream after you wash. Ask your doctor to suggest one.

	Loss of feeling in your feet.
	Changes in the shape of your feet.
	Foot ulcers or sores that do not heal.

	Know when to get checks of your A1C,* blood pressure, and cholesterol.
	Know how and when to test your blood glucose.
	Take your medicines as prescribed.
	Eat regular meals that contain a variety of healthy, low-fat, high-fiber foods including fruits and vegetables each day.
	Get physical activity each day.
	Stop smoking.
	Follow your foot care plan.
	Keep your doctor’s visits and have your feet, eyes, and kidneys checked at least once a year. Visit your dentist twice a year.

	Wash your feet in warm, not hot, water. Do not soak your feet, because your skin will get dry.
	Before bathing or showering, test the water to make sure it is not too hot. You can use a thermometer (90° to 95° F is safe) or your elbow.
	Dry your feet well. Be sure to dry between your toes. Use talcum powder or cornstarch to keep the skin between your toes dry.

	Check the insides of your shoes before you put them on to be sure the lining is smooth and that there are no objects in them.
	Wear shoes that fit well and protect your feet.

	Wear socks at night if your feet get cold. Lined boots are good in winter to keep your feet warm.
	Check your feet often in cold weather to avoid frostbite.
	Make sure to call your doctor right away if a cut, sore, blister, or bruise on your foot does not begin to heal after one day.

	Don’t wear tight socks, elastic or rubber bands, or garters around your legs.
	Don’t smoke. Smoking reduces blood flow to your feet. Ask for help to stop smoking.
	Work with your health-care team to control your A1C (blood glucose), blood pressure and cholesterol.

	Always include a short warm-up and cool-down period.
	Wear athletic shoes that fit well and that provide good support.

	Refer you to a foot care doctor if needed.
	Decide if special shoes would help your feet stay healthy.

	Begin taking good care of your feet today.
	Set a time every day to check your feet.
	Note the date of your next visit to the doctor.
	Print out the foot care tip sheet* and put it on your bathroom or bedroom wall or nightstand as a reminder.
	Print out and complete the "To Do" list*. Get started now.
	Set a date for buying the things you need to take care of your feet: nail clippers, pumice stone, emery board, skin lotion, talcum powder, plastic mirror, socks, athletic shoes, and slippers.
	Most important, stick with your foot care program .... and give yourself a special treat such as a new pair of lightly padded socks with no seams. You deserve it!

	Examine skin, hair, toenails, musculoskeletal structure, and evaluate vascular status, and protective sensation.
	Inspect footwear for proper fit, appropriate materials, foreign objects, torn linings, and proper cushioning.

	Talk with your patients about their risk category.
	Demonstrate self-care techniques.
	Prescribe appropriate footwear.
	Give positive feedback for proper foot care.
	Give patients the self-care tip sheet in this kit.
	Counsel about smoking cessation if needed.
	Reinforce the importance of blood glucose control to reduce the risk for foot problems and other complications.

	Visually inspect feet at subsequent visits as warranted.
	Inspect footwear at every visit as warranted.

	Place a "high risk feet" sticker on medical record.
	Visually inspect feet at every visit.
	Inspect footwear at every visit.
	Prescribe special inserts and shoes as needed.
	Refer to specialists for a risk factor you cannot rectify.
	Ensure that the elderly and blind have help for daily foot care.